Leveraging multisource feedback to address diversity, equity, and inclusivity.

Multisource feedback has long been a recommended tool to assess clinical competencies within graduate medical education. Additionally, incorporating feedback supplied by patients and other members of the healthcare team can provide the framework to bridge perspectives and viewpoints that may be different from their own. This, in effect, can aid in fortifying values in diversity, equity, and inclusivity by developing more knowledgeable, empathetic, and respectful future healthcare providers.

Virtual Reality Simulation for the Middle Cranial Fossa Approach: A Validation Study.

BACKGROUND AND OBJECTIVES: Virtual reality (VR) surgical rehearsal is an educational tool that exists in a safe environment. Validation is necessary to establish the educational value of this platform. The middle cranial fossa (MCF) is ideal for simulation because trainees have limited exposure to this approach and it has considerable complication risk. Our objectives were to assess the face, content, and construct validities of an MCF VR simulation, as well as the change in performance across serial simulations. METHODS: Using high-resolution volumetric data sets of human cadavers, the authors generated a high-fidelity visual and haptic rendering of the MCF approach using CardinalSim software. Trainees from Neurosurgery and Otolaryngology-Head and Neck Surgery at two Canadian academic centers performed MCF dissections on this VR platform. Randomization was used to assess the effect of enhanced VR interaction. Likert scales were used to assess the face and content validities. Performance metrics and pre- and postsimulation test scores were evaluated. Construct validity was evaluated by examining the effect of the training level on simulation performance. RESULTS: Twenty trainees were enrolled. Face and content validities were achieved in all domains. Construct validity, however, was not demonstrated. Postsimulation test scores were significantly higher than presimulation test scores ( P < .001 ). Trainees demonstrated statistically significant improvement in the time to complete dissections ( P < .001 ), internal auditory canal skeletonization ( P < .001 ), completeness of the anterior petrosectomy ( P < .001 ), and reduced number of injuries to critical structures ( P = .001 ). CONCLUSION: This MCF VR simulation created using CardinalSim demonstrated face and content validities. Construct validity was not established because no trainee included in the study had previous MCF approach experience, which further emphasizes the importance of simulation. When used as a formative educational adjunct in both Neurosurgery and Otolaryngology-Head and Neck Surgery, this simulation has the potential to enhance understanding of the complex anatomic relationships of critical neurovascular structures.

Role of Left Ventricular Dysfunction in Systemic Sclerosis-Related Pulmonary Hypertension.

BACKGROUND: In systemic sclerosis (SSc), pulmonary hypertension remains a significant cause of morbidity and mortality. Although conventionally classified as group 1 pulmonary arterial hypertension, systemic sclerosis-related pulmonary hypertension (SSc-PH) is a heterogeneous disease. The contribution of left-sided cardiac disease in SSc-PH remains poorly understood. RESEARCH QUESTION: How often does left ventricular (LV) dysfunction occur in SSc among patients undergoing right heart catheterization and how does coexistent LV dysfunction with SSc-PH affect all-cause mortality in this patient population? STUDY DESIGN AND METHODS: We conducted a retrospective, observational study of 165 patients with SSc who underwent both echocardiography and right heart catheterization. LV dysfunction was identified using LV global longitudinal strain (GLS) on speckle-tracking echocardiography based on a defined threshold of > -18%. SSc-PH was defined by a mean pulmonary artery pressure > 20 mmHg. RESULTS: Among patients with SSc who have undergone right heart catheterization, LV dysfunction occurred in 74.2% with SSc-PH and 51.2% without SSc-PH. The median survival of patients with SSc-PH and LV dysfunction was 67.9 (95% CI, 38.3-102.0) months, with a hazard ratio of 12.64 (95% CI, 1.73-92.60) for all-cause mortality when adjusted for age, sex, SSc disease duration, and FVC compared with patients with SSc without pulmonary hypertension with normal LV function. INTERPRETATION: LV dysfunction is common in SSc-PH. Patients with SSc-PH and LV dysfunction by LV GLS have increased all-cause mortality. This suggests that LV GLS may be helpful in identifying underlying LV dysfunction and in risk assessment of patients with SSc-PH.

Referred otalgia: Common causes and evidence-based strategies for assessment and management.

OBJECTIVE: To provide family physicians and general otolaryngologists with a practical, evidence-based, and comprehensive approach to the management of patients presenting with suspected referred otalgia. SOURCES OF INFORMATION: The approach described is a review based on the authors' clinical practices along with research and clinical review articles published between 2000 and 2020. MEDLINE and PubMed were searched using the terms otalgia, referred otalgia, and secondary otalgia. Current guidelines for the management of referred otalgia were also reviewed. MAIN MESSAGE: Otalgia is defined as pain localized to the ear. It is one of the most common head and neck presentations in primary care, otolaryngology, and emergency medicine. Secondary otalgia arises from nonotologic pathology and represents nearly 50% of otalgia cases. Otalgia in the absence of other otologic symptoms is highly indicative of a secondary cause. A thorough assessment of patients presenting with referred otalgia requires an understanding of the possible causes of this condition, including dental and oral mucosal pathologies, temporomandibular joint disorders, cervical spine pathology, sinusitis, upper airway infection, and reflux, as well as head and neck malignancy. This paper aims to highlight the most common causes of referred otalgia, their presentations, and initial options for assessment and management. CONCLUSION: The prevalence of referred otalgia makes this an important condition for family physicians to be able to assess, manage, and triage based on patient presentation and examination. Understanding the common causes of referred otalgia will help reduce wait times for specialist assessment and allow ease and speed of access to management options for patients in community clinics.

Otalgie référée: Causes habituelles et stratégies d'évaluation et de prise en charge fondées sur des données probantes.

OBJECTIF: Présenter aux médecins de famille et aux otorhinolaryngologistes généraux une approche pratique, exhaustive et fondée sur des données probantes pour la prise en charge des patients chez qui l'on soupçonnne une otalgie référée. SOURCES DE L'INFORMATION: L'approche décrite est une revue qui se fonde sur les pratiques cliniques des auteurs, et sur des articles de recherche et des revues cliniques publiés entre 2000 et 2020. Une recension a été effectuée dans MEDLINE et PubMed à l'aide des expressions en anglais otalgia, referred otalgia et secondary otalgia. Les lignes directrices actuelles sur la prise en charge de l'otalgie référée ont aussi été passées en revue. MESSAGE PRINCIPAL: L'otalgie désigne une douleur localisée à l'oreille. Il s'agit de l'une des présentations liées à la tête et au cou les plus fréquentes en soins primaires, en otorhinolaryngologie et en médecine d'urgence. L'otalgie secondaire découle d'une pathologie non otologique, et près de 50 % des cas d'otalgie lui sont attribuables. L'otalgie sans autres symptômes otologiques évoque fortement une cause secondaire. Une évaluation rigoureuse des patients qui présentent une otalgie référée nécessite une bonne compréhension des causes possibles de ce problème, notamment des pathologies dentaires et des muqueuses buccales, des troubles de l'articulation temporo-mandibulaire, des pathologies de la colonne cervicale, de la sinusite, des infections des voies aériennes supérieures et du reflux, de même que des cancers de la tête et du cou. Cet article a pour but de mettre en évidence les causes les plus fréquentes d'une otalgie référée, leurs caractéristiques, et les options initiales pour l'évaluation et la prise en charge. CONCLUSION: La prévalence de l'otalgie référée fait en sorte qu'il importe que les médecins de famille soient en mesure d'évaluer, de prendre en charge et de trier les patients d'après la présentation et l'examen. Une bonne compréhension des causes courantes de l'otalgie référée aide à réduire le temps d'attente avant une évaluation spécialisée, et permet de faciliter et d'accélérer l'accès par les patients à des options de prise en charge dans les cliniques communautaires.

Infection in Patients on Belatacept Regimen After Kidney Transplant.

OBJECTIVES: A common complication after transplant is an opportunistic infection, in part due to the necessary immunosuppression regimens that patients are placed on. This study aimed to assess the outcomes and rates of infection in kidney transplant recipients on belatacept compared with kidney transplant recipients on standard immunosuppression therapy. MATERIALS AND METHODS: We conducted a matched-pair case-control retrospective analysis of a prospectively recollected database of all adult kidney transplant patients at the SUNY Upstate Medical Hospital from January 1, 2016, to July 31, 2022. RESULTS: Among study patients, 60.5% of patients in the belatacept group and 47.9% of patients in the standard immunosuppression regimen group were diagnosed with an infectious disease during follow-up, although no significant difference was shown between the 2 groups (P = .21). The most common infection in both groups was urinary tract infection, which was comparable between the groups (41.8% vs 50%; P = .42). No significant difference was shown between patients with early and late conversion to belatacept in terms of infection incident and type. CONCLUSIONS: Kidney transplant recipients who were converted to belatacept because of poor renal function had a similar infection rate compared with patients on standard immunosuppression treatment. Neither conversion to belatacept nor timing of conversion changed the risk of infection after kidney transplant. Our findings suggest that physicians may convert a kidney transplant recipient with poor renal function to belatacept without changing the patient's risk of opportunistic infection.

A Clinical Decision Tool for Risk Stratifying Patients with Systemic Sclerosis-Related Pulmonary Hypertension.

We devised a scoring system to identify patients with systemic sclerosis (SSc) at risk for pulmonary hypertension (PH) and predict all-cause mortality. Using 7 variables obtained via pulmonary function testing, echocardiography, and computed tomographic chest imaging, we applied the score to a retrospective cohort of 117 patients with SSc. There were 60 (51.3%) who were diagnosed with PH by right heart catheterization. Using a scoring threshold ≥ 0, our decision tool predicted PH with a sensitivity, specificity, and accuracy of 0.87 (95% CI 0.75, 0.94), 0.74 (95% CI 0.60, 0.84), and 0.80 (95% CI 0.72, 0.87), respectively. When adjusted for age at PH diagnosis, sex, and receipt of pulmonary arterial vasodilators, each one-point score increase was associated with an adjusted HR of 1.19 (95% CI 1.05, 1.34) for all-cause mortality. With further validation in external cohorts, our simplified clinical decision tool may better streamline earlier detection of PH in SSc.

How standardised are antibiotic regimens in otologic surgery?

BACKGROUND: Within otologic surgery, a paucity of well-controlled studies assessing the use of systemic antibiotic to reduce surgical site infections exists. Moreover, discrepancies in wound classification of procedures challenge consensus in antimicrobial prescribing patterns. We sought to compare surgeons from two different health systems to examine how surgeons' prescribing habits compared to practice guidelines for numerous otologic procedures. METHODS: An online questionnaire was distributed to 33 Canadian and 32 Austrian surgeons who regularly perform otologic surgery. Current systemic antibiotic prescribing habits for cochlear implantation, cholesteatoma surgery, stapes surgery, and tympanoplasty ± ossiculoplasty were collected. RESULTS: Eighteen of 33 (54.5%) Canadian surgeons provided responses, while 18 of 32 (56.3%) of Austrian surgeons answered. Clear consistency with clinical practice guidelines exists for pre-operative antibiotics use in cochlear implant surgery and infected cholesteatoma surgery. However, for stapes surgery and tympanoplasty ± ossiculoplasty, consensus is lacking for both pre- and post-operative antibiotic prescribing habits. Notable differences between the two countries include post-operative antibiotics for cochlear implant surgery (Austria: 36.4%, Canada: 71.4%) and uninfected cholesteatoma surgery (Austria: 33.3%, Canada: 77.8%). Across all procedures, both induction and post-operative antibiotic administration was not significantly associated with surgeon seniority when stratified by five-year increments. CONCLUSION: The lack of consensus among each country's otologic surgeons underscores the uncertainty in wound classification and thus, adherence to clinical practice guidelines.

Using augmented reality to guide bone conduction device implantation.

Exact placement of bone conduction implants requires avoidance of critical structures. Existing guidance technologies for intraoperative placement have lacked widespread adoption given accessibility challenges and significant cognitive loading. The purpose of this study is to examine the application of augmented reality (AR) guided surgery on accuracy, duration, and ease on bone conduction implantation. Five surgeons surgically implanted two different types of conduction implants on cadaveric specimens with and without AR projection. Pre- and postoperative computer tomography scans were superimposed to calculate centre-to-centre distances and angular accuracies. Wilcoxon signed-rank testing was used to compare centre-to-centre (C-C) and angular accuracies between the control and experimental arms. Additionally, projection accuracy was derived from the distance between the bony fiducials and the projected fiducials using image guidance coordinates. Both operative time (4.3 ± 1.2 min. vs. 6.6 ± 3.5 min., p = 0.030) and centre-to-centre distances surgery (1.9 ± 1.6 mm vs. 9.0 ± 5.3 mm, p < 0.001) were significantly less in augmented reality guided surgery. The difference in angular accuracy, however, was not significantly different. The overall average distance between the bony fiducial markings and the AR projected fiducials was 1.7 ± 0.6 mm. With direct intraoperative reference, AR-guided surgery enhances bone conduction implant placement while reduces operative time when compared to conventional surgical planning.

The feasibility and safety of eustachian tube dilation with a standard endovascular balloon: a clinical pilot study.

BACKGROUND: Obstructive eustachian tube dysfunction is a common pathology, generally accepted as the underlying cause for chronic ear diseases. Eustachian tube dilation has shown promising results in randomized controlled trials, but is a costly procedure. The aim of the current study was to assess the feasibility of transnasal balloon dilatation of the eustachian tube with an endovascular balloon in the context of ease of use, maneuverability, and safety. METHODS: Clinical pilot study carried out at a university tertiary care facility. In total, twelve patients, were included over a period of 6 months. All patients underwent tympanoplasty or tympanomastoidectomy surgeries. Eustachian tube dilation was carried out transnasal using an endovascular balloon. A computed tomography was carried out after surgery to assess for any potential damages and compared to preoperative imaging studies. Postoperative endoscopy was performed intraoperatively and at follow up to assess for any potential damages. RESULTS: All eustachian tube dilations were carried out successfully. No severe adverse events were noted during the procedure, in the postoperative period, or on imaging studies. Minor adverse events such as mild intraoperative bleeding was managed in a routine fashion. CONCLUSIONS: Balloon dilation of the eustachian tube with the endovascular balloon was feasible and safe in all cases. It is likely a more cost-effective alternative to commercially available balloons with similar designs and specifications. Trial registration The study was registered at clinicaltrials.gov; NCT04809753, initial release February 24th, 2021.

Examining the utility of a photorealistic virtual ear in otologic education.

BACKGROUND: Otolaryngology-head and neck surgical (OHNS) trainees' operating exposure is supplemented by a combination of didactic teaching, textbook reading, and cadaveric dissections. Conventional teaching, however, may not adequately equip trainees with an understanding of complex visuospatial relationships of the middle ear. Both face and content validation were assessed of a novel three-dimensional (3D) photorealistic virtual ear simulation tool underwent face and content validation as an educational tool for OHNS trainees. METHODS: A three-dimensional mesh reconstruction of open access imaging was generated using geometric modeling, which underwent global illumination, subsurface scattering, and texturing to create photorealistic virtual reality (VR) ear models were created from open access imaging and comiled into a educational platform. This was compiled into an educational VR platform which was explored to validate the face and content validity questionnaires in a prospective manner. OHNS post-graduate trainees were recruited from University of Toronto and University of Calgary OHNS programs. Participation was on a voluntary basis. RESULTS: Total of 23 OHNS post-graduate trainees from the two universities were included in this study. The mean comfort level of otologic anatomy was rated 4.8 (± 2.2) out of 10. Senior residents possessed more otologic surgical experience (P < 0.001) and higher average comfort when compared to junior residents [6.7 (± 0.7) vs. 3.6 (± 1.9); P = 0.001]. Face and content validities were achieved in all respective domains with no significant difference between the two groups. Overall, respondents believed OtoVIS was a useful tool to learn otologic anatomy with a median score of 10.0 (8.3-10.0) and strongly agreed that OtoVIS should be added to OHNS training with a score of 10.0 (9.3-10.0). CONCLUSIONS: OtoVIS achieved both face and content validity as a photorealistic VR otologic simulator for teaching otologic anatomy in the postgraduate setting. As an immersive learning tool, it may supplement trainees' understanding and residents endorsed its use.

Hemodynamic Response to Oral Vasodilator Therapy in Systemic Sclerosis-Related Pulmonary Hypertension.

PURPOSE: Although classified as group 1 pulmonary arterial hypertension (PAH), patients with systemic sclerosis-related pulmonary hypertension (SSc-PH) experience poorer clinical response to PAH therapy and increased mortality compared to those with idiopathic PAH. Due to heterogeneity in phenotypes, identifying patients likely to respond to therapy is challenging. The goal of this study was to determine clinical factors associated with hemodynamic response, defined by a > 20% reduction in pulmonary vascular resistance on repeat right heart catheterization. METHODS: We applied a time-to-event model using a retrospective cohort of 39 patients with precapillary SSc-PH, defined by a mean pulmonary artery pressure of ≥ 25 mmHg and pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg on right heart catheterization. RESULTS: Patients with PAWP ≤ 8 mmHg were nearly fourfold more likely to achieve a hemodynamic response compared to those with PAWP > 8 mmHg (HR 3.88; 95% CI: 1.20, 12.57); each 1 mmHg increase in PAWP was associated with a decreased hazard for hemodynamic response (HR 0.84; 95% CI: 0.70, 1.00). CONCLUSION: In patients with precapillary SSc-PH, PAWP was associated with time to hemodynamic response, suggesting the importance of subclinical cardiac disease in determining hemodynamic response to oral vasodilator therapy.

A Multimodal Prediction Model for Diagnosing Pulmonary Hypertension in Systemic Sclerosis.

OBJECTIVE: Diagnosis of pulmonary hypertension (PH) in systemic sclerosis (SSc) requires an invasive right heart catheterization (RHC), often based on an elevated estimated pulmonary artery systolic pressure on screening echocardiography. However, because of the poor specificity of echocardiography, a greater number of patients undergo RHC than necessary, exposing patients to potentially avoidable complication risks. The development of improved prediction models for PH in SSc may inform decision-making for RHC in these patients. METHODS: We conducted a retrospective study of 130 patients with SSc; 66 (50.8%) were diagnosed with PH by RHC. We used data from pulmonary function testing, electrocardiography, echocardiography, and computed tomography to identify and compare the performance characteristics of 3 models predicting the presence of PH: 1) random forest, 2) classification and regression tree, and 3) logistic regression. For each model, we generated receiver operating curves and calculated sensitivity and specificity. We internally validated models using a train-test split of the data. RESULTS: The random forest model performed best with an area under the curve of 0.92 (95% confidence interval [95% CI] 0.83-1.00), sensitivity of 0.95 (95% CI 0.75-1.00), and specificity of 0.80 (95% CI 0.56-0.94). The 2 most important variables in our random forest model were pulmonary artery diameter on chest computed tomography and diffusing capacity for carbon monoxide on pulmonary function testing. CONCLUSIONS: In patients with SSc, a random forest model can aid in the detection of PH with high sensitivity and specificity and may allow for better patient selection for RHC, thereby minimizing patient risk.

The user experience design of a novel microscope within SurgiSim, a virtual reality surgical simulator.

PURPOSE: Virtual reality (VR) simulation has the potential to advance surgical education, procedural planning, and intraoperative guidance. "SurgiSim" is a VR platform developed for the rehearsal of complex procedures using patient-specific anatomy, high-fidelity stereoscopic graphics, and haptic feedback. SurgiSim is the first VR simulator to include a virtual operating room microscope. We describe the process of designing and refining the VR microscope user experience (UX) and user interaction (UI) to optimize surgical rehearsal and education. METHODS: Human-centered VR design principles were applied in the design of the SurgiSim microscope to optimize the user's sense of presence. Throughout the UX's development, the team of developers met regularly with surgeons to gather end-user feedback. Supplemental testing was performed on four participants. RESULTS: Through observation and participant feedback, we made iterative design upgrades to the SurgiSim platform. We identified the following key characteristics of the VR microscope UI: overall appearance, hand controller interface, and microscope movement. CONCLUSION: Our design process identified challenges arising from the disparity between VR and physical environments that pertain to microscope education and deployment. These roadblocks were addressed using creative solutions. Future studies will investigate the efficacy of VR surgical microscope training on real-world microscope skills as assessed by validated performance metrics.

Health State Utility Values Associated with Cochlear Implants in Adults: A Systematic Review and Network Meta-Analysis.

OBJECTIVES: The cost-effectiveness of bilateral cochlear implants in adults remains uncertain despite established clinical benefits. In cost-effectiveness studies, benefit is often measured by change in health state utility value (HSUV), a single number summary of health-related quality of life anchored at 0 (state of being dead) and 1 (perfect health). Small differences in bilateral cochlear implant HSUV change conclusions of published models, and invalid estimates can therefore mislead policy and funding decisions. As such, we aimed to review and synthesize published HSUV estimates associated with cochlear implants. DESIGN: We included observational or experimental studies reporting HSUV for adult patients (age ≥18 years) with at least moderate-profound sensorineural hearing loss in both ears who received unilateral or bilateral cochlear implants. We searched MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases up to May 1, 2021. Study and participant characteristics and HSUV outcomes were extracted. Narrative synthesis is reported for all studies. A Bayesian network meta-analysis was conducted to generate pooled estimates for the mean difference in HSUV for three comparisons: (1) unilateral cochlear implant versus preimplant, (2) bilateral cochlear implants versus preimplant, (3) bilateral versus unilateral cochlear implants. Our principal measure was pooled mean difference in HSUV. RESULTS: Thirty-six studies reporting unique patient cohorts were identified. Health Utilities Index, 3 (HUI-3) was the most common HSUV elicitation method. HSUV from 19 preimplant mean estimates (1402 patients), 19 unilateral cochlear implant mean estimates (1701 patients), and 5 bilateral cochlear implants mean estimates (83 patients) were pooled to estimate mean differences in HUI-3 HSUV by network meta-analysis. Compared with preimplant, a unilateral cochlear implant was associated with a mean change in HSUV of +0.17 (95% credible interval [CrI] +0.12 to +0.23) and bilateral cochlear implants were associated with a mean change of +0.25 (95% CrI +0.12 to +0.37). No significant difference in HSUV was detected for bilateral compared with unilateral cochlear implants (+0.08 [95% CrI -0.06 to +0.21]). Overall study quality was moderate. CONCLUSIONS: The findings of this review and network meta-analysis comprise the best-available resource for parameterization of cost-utility models of cochlear implantation in adults and highlight the need to critically evaluate the validity of available HSUV instruments for bilateral cochlear implant populations.Protocol registration: PROSPERO (CRD42018091838).